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primary care physicians, value-based care, healthcare

Independent practices face the toughest challenge, and the most to gain in value-based care

Value-based care, which incentivizes doctors and health systems to optimize quality and outcomes for their patients rather than volume of healthcare services, is perhaps the most disruptive care delivery innovation in the past decade. Independent primary care providers (PCPs), a cornerstone of our healthcare system, are key to the success of this national paradigm shift. 

PCPs own deep, trusting relationships with their patients and are not as encumbered by the perverse incentives that challenge hospitals and hospital-employed physicians to succeed in providing value-based care. Independent PCPs can focus on reducing hospitalizations, emergency department visits, and referring to the highest quality and value specialists, without concern for a hospital or health system’s bottom line. Through value-based care, independent PCPs are poised to reap the rewards when patients stay healthy and out of the ED or hospital thanks to efforts to increase primary care access and timely preventive services. 

But the transition from the deeply entrenched fee-for-service mindset is extremely challenging, especially for these independent physicians. Today’s independent PCPs are small business owners who have worked to optimize their practice, staff, and overhead to serve their communities, and hopefully turn a healthy profit in the process. Changing a reimbursement structure is a daunting and anxiety-provoking transformation. 

PCPs find themselves asking: Will this payment model fail or disappear in a few years? Are value-based incentives stable or reliable enough to compensate for the revenue lost by cutting potentially unnecessary services and tests for patients? 

Accepting accountability for their entire population of patients also requires work that has not traditionally been reimbursed in the fee-for service-system. First, they have to identify the patients attributed to them (non-trivial, as Medicare and other programs use complicated methodologies for patient attribution). Then they have to engage patients at their individual level of need, which requires data interpretation, risk stratification and care coordination outside of their practice’s walls. 

Finally, total population management requires active outreach to patients who don’t appear often enough or are identified as high-risk or need. All of this work takes workflow redesign and potentially new staffing roles, which can be disruptive (and potentially costly) for independent practices. 

Throughout my work I’ve seen hundreds of independent PCPs make this transition to value-based care, and I can say that despite the inherent challenges, it is worth the effort. From my experience helping physicians make this jump, I can share wonderful stories from providers who, through patient engagement and preventive services, have detected cancers early, captured key verbal clues indicating heart disease, or discovered other critical patient information during the conversational moments allowed in an annual wellness visit.

Take the story of Shawn Purifoy, MD, of Malvern, Arkansas, who epitomizes fierce independence. He serves the community that raised him, after assuming sole proprietorship of the family practice where he was mentored. Dr. Purifoy’s practice was amazing prior to value-based care - he had processes and staffing engineered to accommodate the community’s voracious healthcare needs. A team of nurse practitioners would see a stream of patients that didn’t need his attention; his nurses helped him treat over 60 patients a day, and every patient got high-quality care. The business was profitable, the community was well served. Why would he challenge himself to transition to value?  

Well, because he is bold, intrepid, and savvy. He has also followed the policy debates and understands this is the direction the United States healthcare system is headed, by necessity. Most importantly, he accepted long ago that this is the right thing to do for his patients, and his conscience keeps him on this path. This is important, as value-based models are designed to achieve the healthcare ‘triple-aim’: better care for patients, healthier populations, and lower costs of care.

That doesn’t mean Dr. Purifoy’s path was easy. He had to learn how to accommodate team-based annual wellness visits and transitional care management in a clinic already functioning like a delicate machine, honed precisely for fee-for-service. He had to figure out how to ensure access to medical records after hours among his call group. But through these, and every other value-based care challenge, he has found a way. 

Independent PCPs are at a critical crossroads, as health plans grow their value-based contracting and recently announced policy changes to the Medicare Shared Savings Program provide increasingly favorable terms to entice practices to make the transition. The promise of value-based care for patients, doctors, and society is well worth the effort, and the time has never been better for independent PCPs to do the right thing by their patients and themselves.

Emily Maxson, MD, is senior vice president, Medical Affairs and Product, Aledade.